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Pattern and Predictors of Soil-Transmitted Helminth Reinfections among Orang Asli (aborigine) Schoolchildren in Malaysia Hesham MS. Al-Mekhlafi , Atiya AS., Mohammed AK. Mahdy, WA Wan Ariffin, H Che Abdullah and Johari Surin 19 January 2008 19

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Pattern and Predictors of Soil-Transmitted Helminth Reinfections among Orang Asli (aborigine) Schoolchildren in Malaysia

Hesham MS. Al-Mekhlafi, Atiya AS., Mohammed AK. Mahdy, WA Wan Ariffin, H Che Abdullah and Johari Surin

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INTRODUCTION INTRODUCTION

  • Intestinal parasitic infections are major health

Intestinal parasitic infections are major health problems worldwide problems worldwide developing countries developing countries rural rural communities communities. .

  • More than one billion of the world

More than one billion of the world’ ’s population are s population are infected either by one or more of infected either by one or more of STH STH, particularly , particularly Ascaris Ascaris lumbricoides lumbricoides, , Trichuris Trichuris trichiura trichiura and and hookworm hookworm (WHO 2002)

(WHO 2002).

.

  • Neglected diseases

Neglected diseases

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Continued Continued…… ……

  • ‘the cancers of developing nations’ according to

according to Egger

Egger et al. et al. (1990) (1990).

.

  • Complications

Complications

  • Retarded growth

Retarded growth (

(Stoltzfus Stoltzfus et al. et al. 1997; Al 1997; Al-

  • Mekhlafi

Mekhlafi et al. et al. 2005) 2005)

  • Micronutrient deficiencies (IDA & VAD)

Micronutrient deficiencies (IDA & VAD) (

(Dreyfuss Dreyfuss et al. et al. 2000; 2000; Congsbak Congsbak et al. et al. 2006) 2006)

  • Impaired learning and school performance

Impaired learning and school performance (

(Nokes Nokes & Bundy 1994; & Bundy 1994; Ezeamama Ezeamama et al. et al. 2005) 2005)

  • Adulthood

Adulthood Shorten working life & reduce working capacity Shorten working life & reduce working capacity

( (Guyatt Guyatt 2000; 2000; Gilgen Gilgen et al. et al. 2001) 2001)

  • Increase the cost of health care

Increase the cost of health care

  • …

….. .. Death Death (STH together with (STH together with schistosomiasis schistosomiasis represented more than 40% of represented more than 40% of the disease burden caused by all tropical diseases, excluding ma the disease burden caused by all tropical diseases, excluding malaria) laria) (WHO 1999)

(WHO 1999)

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Continued Continued…… ……

  • In Malaysia

In Malaysia

  • Since 1970s

Since 1970s high prevalence high prevalence

  • Highly prevalent in

Highly prevalent in Orang Orang Asli Asli communities. communities.

  • Prevalence of

Prevalence of ascariasis ascariasis, , trichuriasis trichuriasis and and hookworm hookworm infections in rural areas range between infections in rural areas range between 30.2 30.2– –69.0%, 15.8 69.0%, 15.8– –98% and 6 98% and 6– –51.0%, respectively 51.0%, respectively

( (Norhayati Norhayati et al. 1997; et al. 1997; Zulkifli Zulkifli et al 2000; Al et al 2000; Al-

  • Mekhlafi

Mekhlafi et al. 2006) et al. 2006)

  • Trichuriasis

Trichuriasis was the predominant infection. was the predominant infection.

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Continued Continued…… …… WEB OF CAUSATION WEB OF CAUSATION WEB OF CAUSATION

STH STH STH

Resistant to anthelmintics Demography Animals Inadequate Health Care Flies and

  • thers arthropods

Poor personal hygiene Contaminated Environment (soil & water) Poverty (poor socioeconomic status) Geophagy Poor health education Inadequate sanitation

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PROBLEM STATEMENT PROBLEM STATEMENT

  • Despite:

Despite:

great development in socioeconomic status great development in socioeconomic status several several deworming deworming programs programs… …, , Malaysia is still plagued with STH. Malaysia is still plagued with STH. STH continue to have significant impact on STH continue to have significant impact on public health particularly among rural children public health particularly among rural children

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OBJECTIVES OBJECTIVES

  • To determine the current prevalence of STH

To determine the current prevalence of STH among rural schoolchildren. among rural schoolchildren.

  • To investigate the pattern of STH

To investigate the pattern of STH reinfections reinfections. .

  • To investigate the possible risk factors of

To investigate the possible risk factors of reinfections reinfections

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METHODOLOGY METHODOLOGY

  • Study Area

Study Area

Sekolah Sekolah Kebangsaan Kebangsaan Betau Betau Pos Pos Betau Betau, Kuala , Kuala Lipis Lipis, , Pahang Pahang, Malaysia , Malaysia.

. (200 km from Kuala Lumpur)

18 Orang Asli villages

( (120 120) ) Primary Schoolchildren Age: 7-12 years Male/Female: 60/60

  • Subjects

Subjects

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METHODOLOGY METHODOLOGY

Data Analysis Faecal samples from Orang Asli schoolchildren Questionnaire Formol-ether sedimentation method Kato-Katz technique Harada Mori technique Complete Deworming 3-days course Albendazole 400mg

Examined for efficacy

Faecal samples examined after 3 and 6 months

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RESULTS RESULTS

Prevalence of STH among Prevalence of STH among Orang Orang Asli Asli schoolchildren according to schoolchildren according to severity of infection and gender severity of infection and gender

Intensity of infection

10.8 10.8 97.5 97.5 65.8 65.8 Total (%) Total (%)

4 (6.7) 141 (96.7) 40 (66.7) Female 9 (15.0) 58 (98.3) 39 (65.0) Male Gender 35 (29 (29.2) 2) 17 (14 (14.2) 2) Heavy i avy infectio ion 33 (27.5) 24 (20.0) Moderate infection 13 (10.8) 49 (40.8) 38 (31.7) Light infection 106 (88.3) 3 (2.5) 41 (34.2) Negative Hookworm infection

  • No. (%)

Trichuriasis

  • No. (%)

Ascariasis

  • No. (%)

Type of infections

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STH STH reinfection reinfection

Reinfection rates and reinfection intensities of STH over a period of 6 months after deworming among Orang Asli schoolchildren in Pos Betau, Pahang (n=120)

0.12 0.12 2.37 2.37 2.10 2.10 6 months 0.07 1.16 0.68 3 months 0.28 0.28 3.30 3.30 2.58 2.58 Baseline Reinfection intensities b 51.8 51.8 67.4 67.4 73.1 73.1 6 months 33.3 39.7 28.7 3 months Reinfection rates (%) a 5.6 65.7 48.1 6 months 3.6 38.7 18.9 3 months 10.8 97.5 65.8 Baseline Prevalence (%) Hookworm Trichuris Ascaris

a Number of infected children after deworming/ number of infected children before deworming b Geometric mean counts of egg per gram faeces

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Total reinfection rates of STH after 3 and 6 months of deworming 80.3 80.3 51.9 66.5 73.1 At 6 months % 48.9 48.9 33.3 38.8 28.7 At 3 months % Total Hookworm Trichuris Ascaris

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Continued Continued… ….. ..

Potential predictors of STH reinfection in rural Malaysian communities (Logistic regression)

42 (87.5) 44 (73.3) 30 (61.2) a 25 (40.3) Nutritional status Stunted children Non-stunted children 18 (78.3) 68 (80.0) 9 (37.5) 46 (52.9) Have animals in house: Yes No 77 (81.1) 9 (69.2) 48 (50.0) 7 (46.7) Source of drinking water: Piped Others (river, rain, well) 23 (71.9) 63 (82.9) 10 (30.3) 45 (57.7) a, b Toilet in house: Yes No 20 (80.0) 66 (79.5) 14 (56.0) 41 (47.7) Family size ≥ 8 members (large) < 8 members 63 (78.8) 23 (82.1) 38 (45.8) 17 (60.7) Low household income: <RM450/month ≥RM450/month 48 (90.5) a, b 38 (72.7) 31 (57.1) 24 (44.9) Mothers’ employment status: Working Not working 19 (90.5) 67 (77.0) 11 (50.0) 44 (49.4) Mothers’ educational levels: ≥6 years formal education No formal education 31 (77.5) 55 (80.9) 20 (48.8) 35 (50.0) Fathers’ educational levels: ≥6 years formal education No formal education 37 (68.5) 49 (90.7) a, b 17 (30.9) 38 (67.9) a, b Gender: Male Female 67 (79.8) 19 (79.2) 40 (46.0) 15 (62.5) Age: ≤10 years >10 years At 6 months n (%) At 3 months n (%) Reinfection rates of STH Variables

a Significant association (P< 0.05) b Confirmed as significant predictors by

logistic regression analysis

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Some potential source of infections in this area Some potential source of infections in this area

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DISCUSSION DISCUSSION

  • STH is highly prevalent among aboriginal children

STH is highly prevalent among aboriginal children and this may indicate the continuance of this problem. and this may indicate the continuance of this problem.

( (Dissanaike Dissanaike et al. et al. 1977 1977; Bundy et al. ; Bundy et al. 1988 1988; ; Norhayati Norhayati et al. et al. 1997 1997; ; Zulkifli Zulkifli et al. et al. 2000 2000; Al ; Al-

  • Mekhlafi

Mekhlafi et al. et al. 2006 2006). ).

  • Trichuriasis

Trichuriasis is the commonest STH infection in is the commonest STH infection in Malaysia with high percentage of severe infections Malaysia with high percentage of severe infections

( (Norhayati Norhayati et al. 1997; et al. 1997; Sagin Sagin et al. 2002; et al. 2002; Al Al-

  • Mekhlafi

Mekhlafi et al. 2006). et al. 2006).

  • Ascariasis

Ascariasis in China in China 600 million people 600 million people (Xu et al. 1995)

  • Ascariasis

Ascariasis in in Yemen Yemen (Azazy et al. 2002), Indonesia Indonesia (Widjana & Sutisna 2000), Brazil Brazil (Scolari et al. 2000). -

  • Hookworm in Nigeria

Hookworm in Nigeria (Adenusi et al. 2003),

, aborigines in Northern Australia

aborigines in Northern Australia (Thompson et al. 2001).

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continued continued

  • High

High reinfection reinfection rate rate almost 80% of the almost 80% of the children were found to be children were found to be reinfected reinfected with STH with STH by six months after complete by six months after complete deworming deworming

  • continuous exposure

continuous exposure

Lack of sanitation and employment status of

mothers were identified as significant predictors of STH and this was in accordance with previous studies (Muller et al. 1989; Rai et al. 2000; Naish et al. 2004).

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The egg count of A. lumbricoides infections at 6

months was almost similar to the baseline situation.

Likewise, the egg counts of T. trichiura and

hookworm reinfections were two third and one half of the baseline situation. . continued continued

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Prevalence and reinfection rates of STH are still very

high in rural Malaysian communities. Thus

necessitate frequent and periodic deworming

among children to reduce parasitic loads, alleviate acute disease and help to reduce transmission

CONCLUSION CONCLUSION

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Public health personnel need to

re-look at the current control measures and identify innovative and integrated ways in order to reduce STH significantly in the rural communities.

Improvement of socioeconomic status, sanitation,

health education together with periodic mass deworming are recommended to control STH.

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THANK YOU